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The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 33 Results
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.
Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.
Arntson E, Dimick JB, Nuliyalu U, et al. Ann Surg. 2021;274:e301-e307.
Hospital-acquired conditions (HACs) are thought to be preventable, and the Centers for Medicare & Medicaid Services (CMS) reduce payments to hospitals with the highest rates of these conditions through its Hospital-Acquired Condition Reduction Program (HACRP). This study evaluated surgical HACs at three timepoints: before Affordable Care Act (ACA) implementation, after ACA implementation, and after HACRP. While the number of HACs continued to decline after implementation of HACRP, it did not affect 30-day mortality.
Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
Synan LT, Eid MA, Lamb CR, et al. Surgery. 2021;170:764-768.
This study compared unsolicited hospital reviews posted online by patients with Hospital Compare patient satisfaction and postsurgical safety indicators. While there was variation in consumer ratings between platforms, unstructured consumer reviews were generally correlated with Hospital Compare patient satisfaction scores; consumer platforms were not consistently correlated with postsurgical patient safety indicators.
KM B. New York Univ Law Rev. 2020;95:1229-1318.
Maternal death or harm is disproportionately experienced by women of color in the United States. This perspective discusses legislative efforts to address discrepancies affecting the safety of this patient population. The author reviews weaknesses of this approach which include a lack of emphasis on state-level analysis of the problem to address system-level contributors to the problem.
Petersen EE, Davis NL, Goodman D, et al. MMWR Morb Mortal Wkly Rep. 2019;68:423-429.
Maternal safety is a critical concern in health care, and prior studies have discussed racial and ethnic disparities in patient safety. The Centers for Disease Control and Prevention examined trends in pregnancy-related deaths between 2011 and 2015. This analysis found that black women had rates of maternal mortality 3.5 times that of white women; Native American/Alaska Native women had rates 2.5 times higher than white women. About 60% of deaths were deemed preventable, and leading causes included cardiovascular events such as venous thromboembolism, infection, and hemorrhage. The study team recommends implementing interventions at health system, provider, community, and patient levels to prevent maternal mortality. A recent Annual Perspective on maternal safety touched on the persistently higher death rates among black women and discussed national initiatives to improve outcomes in maternity care.
Mora JC, Kaye AD, Romankowski ML, et al. Adv Anesth. 2018;36:231-249.
Closed claim analysis can identify care problems and inform improvement strategies. This review examined closed claims for anesthesia and identified types of injuries experienced by patients receiving anesthesia. Situational awareness, distractions, equipment problems, and pain medicine complications contributed to anesthesia malpractice claims.
Kozhimannil KB. Health Aff (Millwood). 2018;37:1901-1904.
Maternal harm is a sentinel event that is gaining increased attention in both policy and clinical environments. In this commentary, the author relates her family history of maternal morbidity and mortality and advocates for enhancements in collecting data on maternal health outcomes, access to care, understanding of racial disparities, accountability, and listening to patients and families who have been impacted by unsafe maternal care.
Lemoine N, Dajer A, Konwinski J, et al. J Healthc Risk Manag. 2018;38:48-53.
Analysis of closed malpractice claims has been used to characterize safety hazards in a variety of clinical settings. This study used retrospective review of malpractice claims to examine the underlying causes of diagnostic error in the emergency department as well as identify potential systems solutions. The senior author of this study, Dr. Hardeep Singh, discussed the evolving diagnostic error field in a PSNet perspective.
Lagoo J, Berry WR, Miller K, et al. Ann Surg. 2019;270:84-90.
Physicians who receive more patient complaints about communication and behavior are more likely to face malpractice claims. This study examined whether results from surgeons' 360-degree reviews, in which team members evaluate a range of professional attributes and behaviors, were associated with risk of malpractice claims. Surgeons with worse performance for attentiveness, informing others, and considering others' suggestions had a significantly higher risk for malpractice claims. Surgeons in the highest 10% for the negative behaviors of snapping at or talking down to others also were more likely to have malpractice claims. These results echo prior studies of physician behavior and malpractice risk. The authors suggest that addressing negative behaviors among surgeons could mitigate malpractice risk. A previous WebM&M commentary discussed patient complaints as safety surveillance.
Bathla S, Chadwick M, Nevins EJ, et al. J Patient Saf. 2021;17:e503-e508.
Wrong-site surgery represents a never event. In the United States, The Joint Commission requires marking of the surgical site prior to surgery as part of the Universal Protocol. Researchers conducted a survey study of 120 surgeons in the United Kingdom and found significant variation in adherence to the national mandate for preoperative surgical site-marking.
Mello MM, Greenberg Y, Senecal SK, et al. Health Serv Res. 2016;51 Suppl 3:2583-2599.
Communication-and-resolution programs underscore the importance of early disclosure of medical error to patients and families. Prior research highlights implementation challenges associated with these efforts. Investigators analyzed 125 adverse event cases from 5 New York City hospitals over a 22-month period following the implementation of communication-and-resolution programs. The majority of cases did not involve substandard care, and disclosure occurred in more than 90% of cases.
Riley W, Meredith LW, Price R, et al. Health Serv Res. 2016;51:2453-2471.
Improving patient safety provides an opportunity to reduce malpractice claims and associated costs, particularly in higher risk clinical areas such as obstetrics. This study examined medical malpractice claims and cost data in the perinatal units of hospitals before and after implementation of safety interventions focused on decreasing perinatal harm. Interventions consisted largely of standardizing best practices and implementing team training. Investigators found that improving perinatal safety led to substantial reductions in both the frequency and total cost of malpractice claims. The role that the medical liability system plays in driving up health care costs and in promoting the practice of defensive medicine—which can lead to adverse events through unnecessary tests and procedures—was highlighted in a past WebM&M commentary.
Katlic MR, Coleman JA. Adv Surg. 2016;50:93-103.
Senior clinicians often elicit respect from their junior colleagues. This respect can affect colleagues' willingness to intervene should they observe poor performance in their role models. This review discusses the need to manage aging surgeons appropriately as a matter of safety. The authors recommend that peer support, confidential skill assessments, and effective policy can help hospitals track changes in surgeon performance to mitigate potential safety problems while preserving the dignity of their clinical staff.
Mentis HM, Chellali A, Manser K, et al. Surg Endosc. 2016;30:1713-24.
This systematic review found that equipment and procedural distractions were the most severe distraction events during surgery, but irrelevant conversation and movement were the most frequent. This underscores the need to reduce distractions and incorporate management of distractions into surgical education.
Eappen S, Lane BH, Rosenberg B, et al. JAMA. 2013;309:1599-606.
The business case for patient safety relies on the assumption that adverse events are financially harmful to hospitals over the long term, so up-front investment in safety improvement will eventually result in savings. However, this study cogently demonstrates that—at least for the specific case of surgical complications—hospitals actually profit when patients experience adverse events. Analysis of more than 30,000 surgical procedures revealed that hospitals received significantly greater net reimbursement for patients who experienced complications compared with those who had no complications. This disparity was particularly evident for patients with private insurance, although it was present to a lesser extent for patients with Medicare. This counterintuitive finding vividly demonstrates that, despite efforts such as the Centers for Medicare and Medicaid Services' policy of not paying for errors, payment incentives are not aligned to the extent that would truly encourage innovative approaches to improving safety. As the noted health economist Dr. Uwe Reinhart points out in his accompanying editorial, the findings of this study arise directly from a payment system that rewards providers for the volume rather than the quality of service provided.
Naessens JM, Campbell CR, Shah N, et al. Am J Med Qual. 2012;27:48-57.
The epidemiology of adverse events on a population basis has been well studied, but how these data translate to risks for individual patients is not as clear. The likelihood of suffering an adverse event is directly tied to length of hospitalization, and this study sought to evaluate a complementary question: whether patients who are more severely ill at admission are at increased risk of preventable harm. By linking adverse event data from various sources—including Patient Safety Indicators, voluntary error reports, and infection control reports—to clinical databases, the authors were able to show that higher illness severity is associated with an increased risk of adverse events during hospitalization. These findings are supported by the fact that intensive care unit patients have consistently been shown to experience more adverse events. An AHRQ WebM&M commentary discusses a case of a medication error occurring in an acutely ill patient with multiple underlying comorbidities.
Nicholas LH, Osborne NH, Birkmeyer JD, et al. Arch Surg. 2010;145:999-1004.
Hospitals are now required to report adherence to measures intended to prevent post-surgical complications, including surgical site infections. These measures are being publicly reported by groups including the Centers for Medicare and Medicaid Services. However, this analysis found that high levels of adherence to these accountability measures were not correlated with postoperative mortality, surgical site infection rate, or other complications, calling into question the value of public reporting of such measures.